Table 2. Association Between Receiving Advice to Lose Weight From a
Physician or Health Care Professional and Self-reported Attempts to Lose Weight
Among Obese Persons Who Had % a Routine Checkup in the Previous 12 Months*

National Institutes of Health. Clinical Guidelines on the Identification, Evaluation,
and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, Md: National Institutes of Health, US Dept of Health and
Human Services; 1998.

Objectives To describe the proportion and characteristics of obese persons advised
to lose weight by their health care professional during the previous 12 months
and to determine whether the advice was associated with reported attempts
to lose weight.

Setting Population-based sample from 50 states and the District of Columbia.

Participants A total of 12,835 adults, 18 years and older, classified as obese (body
mass index ≥30 kg/m2), who had visited their physician for a
routine checkup during the previous 12 months.

Main Outcome Measures Reported advice from a health care professional to lose weight, and
reported attempts to lose weight.

Results Forty-two percent of participants reported that their health care professional
advised them to lose weight. Using multivariate logistic regression analysis,
we found that the persons who were more likely to receive advice were female,
middle aged, had higher levels of education, lived in the northeast, reported
poorer perceived health, were more obese, and had diabetes mellitus. Persons
who reported receiving advice to lose weight were significantly more likely
to report trying to lose weight than those who did not (OR, 2.79; 95% CI,
2.53-3.08).

Conclusions Less than half of obese adults report being advised to lose weight by
health care professionals. Barriers to counseling need to be identified and
addressed.

Nearly one fourth of US adults are obese, which is defined as having
a body mass index (BMI) of 30 kg/m2 or more1
and thus are at risk for numerous chronic health conditions.2
Clinicians treating obese patients have an opportunity not only to improve
the health of these individuals but also to affect positively the nation's
public health by implementing the Clinical Guidelines on
the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults.3 In these 1998 guidelines, an
expert panel convened by the National Institutes of Health, recommended that
all obese persons should try to lose weight and that health care professionals
should discuss weight control with their obese patients. This study, using
data from 1996 Behavioral Risk Factor Surveillance System (BRFSS), describes
the proportion and characteristics of obese persons who received advice about
weight loss from their health care professional and determines whether this
advice was associated with attempts to lose weight.

Methods

The BRFSS is an ongoing random-digit telephone survey conducted by state
health departments and the Centers for Disease Control and Prevention.4 In 1996, all 50 states and the District of Columbia
selected independent probability samples of noninstitutionalized adults aged
18 years and older and queried them with a standardized questionnaire. The
median cooperation rate (completed interviews/[completed interviews + refusals])
was 78%. Data from states are pooled for this analysis. From the 122,268 persons
surveyed, we excluded women who were pregnant (n = 1809) and persons who did
not report values for their weight or height (n = 4678). We then used self-reported
weight and height to calculate a BMI, weight in kilograms divided by the square
of height in meters, and defined those participants with a BMI of 30 kg/m2 or more as obese.3

Among 18,827 obese respondents, we excluded those who had missing information
on weight control (n = 680) or explanatory (n = 405) variables and those who
did not visit their physicians for a routine checkup within the previous 12
months (n = 4907). Our analytic sample consisted of 12,835 participants.

To the question: "In the past 12 months, has a doctor, nurse, or other
health professional given you advice about your weight?", respondents were
provided with 1 of the following responses; yes, lose weight; yes, gain weight;
yes, maintain current weight; or no. Participants who reported they were advised
to lose weight were classified as having received advice to lose weight. All
others were classified as not having received advice to lose weight. We classified
those who responded positively to the question, "Are you now trying to lose
weight?" as persons attempting to lose weight.

We conducted analyses with SUDAAN5 to
account for weighting and complex sampling. We used multivariate logistic
regression to characterize associations between explanatory variables and
outcomes.

Results

Of the obese persons who visited their physician for a routine checkup
during the previous 12 months, 42% reported that they had been told by a health
care professional to lose weight ((Table
1). Among factors associated with having received advice, the most
notable were the strong associations between measures of health and the reported
receipt of advice. Persons with diabetes mellitus vs those without, persons
who perceived their health as poor or fair vs those who perceived their health
as excellent, and persons with a BMI of 35.0 kg/m2 or higher vs
those with a BMI of less had 2 to 3 times the odds of receiving advice.

Participants who reported receiving advice were more likely to be women,
have some college education, and live in the Northeast than their counterparts.
The proportion of the participants who had received advice to lose weight
increased with age up to 60 years, after which the proportion declined.

Two thirds of obese participants reported that they were trying to lose
weight. Those whose health care professional told them to lose weight had
nearly 3 times the odds of attempting to lose weight than did those who had
not (Table 2). However, even among
those who had received advice and were trying to lose weight, only 56% used
the recommended strategy of combining diet and physical activity.

Comment

In 1996, nearly half of obese persons who had visited their physician
for a routine checkup during the past 12 months reported receiving advice
to lose weight, a finding consistent with the results of Friedman et al.6 The receipt of advice was associated with health and
demographic characteristics of the participant, as well as with reported attempts
to lose weight.

That nearly half of respondents reported being advised to lose weight
even before the publication of the NIH guidelines is not surprising because
physicians consider issues related to obesity and weight control important.7,8 However, our results suggest health
care professionals may be selective in whom they advise, for 3 reasons: (1)
health care professionals may advise about weight loss when they perceive
that their patients have weight-related conditions such as diabetes mellitus
and could clinically benefit from weight loss7;
(2) health care professionals may be pessimistic about the ability of their
patients to make lifestyle changes9 and, thus,
may target their advice about weight loss to persons they believe most likely
to undertake weight loss behaviors such as women,10,11
those who are highly educated,10 and those
who are most overweight11; and (3) health care
professionals may be more likely to advise weight loss when they have increased
patient contact. Persons who visit physicians more frequently include women,12 those who are at least middle aged,12
those who are overweight,13 and those who have
diabetes mellitus.14

Our study has several limitations. Patient reports may not necessarily
reflect the actions of a physician during office visits. However, unpublished
data from the 1995 National Ambulatory Medical Care Survey suggest our estimates
may provide a reasonable estimate of physician practices. In this survey,
physicians recorded that they counseled about weight reduction during 56%
of the general medical examination visits of patients they perceived to be
obese. Our sample likely misses marginally obese persons because overweight
respondents may have underreported their weight.15
Since the prevalence of counseling increases with increasing levels of obesity,
our estimates may overestimate the true prevalence. Telephone surveys also
may overestimate the true prevalence of counseling. Although persons without
telephones have similar levels of overweight as persons with telephones, persons
without telephones tend to be less educated,16
a factor associated with lower levels of counseling in our study. Also, of
concern is the potential bias caused by those who refused to participate as
well as those who refused to respond to questions about weight. Furthermore,
because data were collected cross-sectionally, we cannot infer that counseling
preceded a patient's attempt to lose weight.

Because weight loss can reduce risk factors for chronic diseases,3 health care professionals need to discuss weight loss
with the 58% of obese patients not currently advised to lose weight. Although
limited in number, studies have reported reductions in weight,17
reductions in fat consumption,18 and increases
in physical activity levels19,20
by patients who received information briefly in a primary care setting. To
increase counseling, perceived barriers such as lack of reimbursement,21 limited time during office visits,21
physicians' lack of training in counseling,21
or physicians' low confidence in their ability to counsel21
or to change the behaviors of their patients21- 24
need to be addressed.

National Institutes of Health. Clinical Guidelines on the Identification, Evaluation,
and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, Md: National Institutes of Health, US Dept of Health and
Human Services; 1998.